Provider Demographics
NPI:1285713271
Name:GRAYSON, ROGER C (PAC MPAB)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:GRAYSON
Suffix:
Gender:M
Credentials:PAC MPAB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 SOUTH L STREET SUITE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-383-5949
Mailing Address - Fax:253-383-5953
Practice Address - Street 1:419 SOUTH L STREET SUITE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-383-5949
Practice Address - Fax:253-383-5953
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGR6977OtherREGENCE BLUE SHIELD
WA1784206OtherPREMERA BLUE CROSS
WAGAB25485OtherMEDICARE PIERCE COUNTY
WA8357030Medicaid
WAS28981Medicare UPIN